4 This form works as new and editing,
7 <TABLE span
class=text
>
8 <th
><H2
><U
>Pediatric Fever Form
</U
></H2
></th
>
12 <INPUT TYPE
="text" NAME
="fever_temp" value
="<? if ($obj["fever_temp
"]!='') print $obj["fever_temp
"]; ?>">
16 <SELECT NAME
="measured">
17 <option
<?
if ($obj["measured"]=='axillary') print 'selected' ;?
> >axillary
18 <option
<?
if ($obj["measured"]=='oral') print 'selected' ;?
> >oral
19 <option
<?
if ($obj["measured"]=='rectal') print 'selected' ;?
> >rectal
20 <option
<?
if ($obj["measured"]=='not measured') print 'selected' ;?
> >not measured
25 <SELECT NAME
="duration">
26 <option
<?
if ($obj["duration"]=='one hour') print 'selected'; ?
>>one hour
27 <option
<?
if ($obj["duration"]=='twelve hours') print 'selected'; ?
>>twelve hours
28 <option
<?
if ($obj["duration"]=='one day') print 'selected'; ?
>>one day
29 <option
<?
if ($obj["duration"]=='two days') print 'selected'; ?
>>two days
30 <option
<?
if ($obj["duration"]=='three days') print 'selected'; ?
>>three days
31 <option
<?
if ($obj["duration"]=='more than 3 days') print 'selected'; ?
>>more than
3 days
36 <TD
>Takink Medication
:</TD
>
38 <SELECT NAME
="taking_medication">
39 <option
<?
if ($obj["taking_medication"]=='no') print 'selected'; ?
>>no
40 <option
<?
if ($obj["taking_medication"]=='yes') print 'selected'; ?
>>yes
42 <TD
>Responds to Tylenol
:</TD
>
44 <SELECT NAME
="responds_to_tylenol">
45 <option
<?
if ($obj["responds_to_tylenol"]=='n/a') print 'selected'; ?
>>n
/a
46 <option
<?
if ($obj["responds_to_tylenol"]=='no') print 'selected'; ?
>>no
47 <option
<?
if ($obj["responds_to_tylenol"]=='yes') print 'selected'; ?
>>yes
49 <TD
>Responds to Molrtin
</TD
>
51 <SELECT NAME
="responds_to_moltrin">
52 <option
<?
if ($obj["responds_to_moltrin"]=='n/a') print 'selected'; ?
>>n
/a
53 <option
<?
if ($obj["responds_to_moltrin"]=='no') print 'selected'; ?
>>no
54 <option
<?
if ($obj["responds_to_moltrin"]=='yes') print 'selected'; ?
>>yes
62 <option
<?
if ($obj["pain"]=='no pain') print 'selected' ;?
> >no pain
63 <option
<?
if ($obj["pain"]=='moderate') print 'selected'; ?
>>moderate
64 <option
<?
if ($obj["pain"]=='intense') print 'selected'; ?
>>intense
65 <option
<?
if ($obj["pain"]=='severe') print 'selected'; ?
>>severe
70 <SELECT NAME
="lethargy">
71 <option
<?
if ($obj["lethargy"]=='no') print 'selected'; ?
>>no
72 <option
<?
if ($obj["lethargy"]=='yes') print 'selected'; ?
>>yes
77 <SELECT NAME
="vomiting">
78 <option
<?
if ($obj["vomiting"]=='no') print 'selected'; ?
>>no
79 <option
<?
if ($obj["vomiting"]=='yes') print 'selected'; ?
>>yes
85 <TD colspan
=2 >Able to take oral hydration
:</TD
>
87 <SELECT NAME
="oral_hydration_capable">
88 <option
<?
if ($obj["oral_hydration_capable"]=='yes') print 'selected'; ?
>>yes
89 <option
<?
if ($obj["oral_hydration_capable"]=='no') print 'selected'; ?
>>no
92 <TD colspan
=2 >Urine output at least every
6 hrs
.</TD
>
94 <SELECT NAME
="urine_output_last_6_hours">
95 <option
<?
if ($obj["urine_output_last_6_hours"]=='yes') print 'selected'; ?
>>yes
96 <option
<?
if ($obj["urine_output_last_6_hours"]=='no') print 'selected'; ?
>>no
99 <SELECT NAME
="pain_with_urination">
100 <option
<?
if ($obj["pain_with_urination"]=='no') print 'selected'; ?
>>no
101 <option
<?
if ($obj["pain_with_urination"]=='yes') print 'selected'; ?
>>yes
107 <TD colspan
=2 >Cough
or difficulty breathing
:</TD
>
109 <SELECT NAME
="cough_or_breathing_difficulty">
110 <option
<?
if ($obj["cough_or_breathing_difficulty"]=='no') print 'selected'; ?
>>no
111 <option
<?
if ($obj["cough_or_breathing_difficulty"]=='yes') print 'selected'; ?
>>yes
114 <TD colspan
=2 >Able to sleep confortably
</TD
>
116 <SELECT NAME
="able_to_sleep">
117 <option
<?
if ($obj["able_to_sleep"]=='yes') print 'selected'; ?
>>yes
118 <option
<?
if ($obj["able_to_sleep"]=='no') print 'selected'; ?
>>no
123 <TD
>Nasal Discharge
:</TD
>
125 <SELECT NAME
="nasal_discharge">
126 <option
<?
if ($obj["nasal_discharge"]=='no') print 'selected'; ?
>>no
127 <option
<?
if ($obj["nasal_discharge"]=='yes') print 'selected'; ?
>>yes
130 <TD
>Prior Hospitalization
</TD
>
132 <SELECT NAME
="previous_hospitalization">
133 <option
<?
if ($obj["previous_hospitalization"]=='no') print 'selected'; ?
>>no
134 <option
<?
if ($obj["previous_hospitalization"]=='yes') print 'selected'; ?
>>yes
137 <TD
>Siblings affected?
:</TD
>
139 <SELECT NAME
="siblings_affected">
140 <option
<?
if ($obj["siblings_affected"]=='no') print 'selected'; ?
>>no
141 <option
<?
if ($obj["siblings_affected"]=='yes') print 'selected'; ?
>>yes
146 <TD colspan
=2 valign
="top">Immunization up to date
:
147 <SELECT NAME
="immunization_up_to_date">
148 <option
<?
if ($obj["immunization_up_to_date"]=='yes') print 'selected'; ?
>>yes
149 <option
<?
if ($obj["immunization_up_to_date"]=='no') print 'selected'; ?
>>no
152 <TD colspan
=4 align
=left valign
=top
>Notes
:
153 <TEXTAREA NAME
="notes" ROWS
="3" COLS
="40">
154 <?
if ($obj["notes"]!='') print $obj["notes"]; ?
>